Child Protective Systems Oversight Committee

Annual Report

2013

An annual report to the Sacramento County Board of Supervisors from the Sacramento County Childrens Coalition, Child Protective Systems Oversight Committee.

ACKNOWLEDGEMENTS The Sacramento County Child Protective Services Systems Oversight Committee (Oversight Committee) of the Sacramento County Childrens Coalition studies and monitors the state of the child protective system in Sacramento County at the behest of the County Board of Supervisors. Since its inception in 1996, the Oversight Committee has produced regular reports to the Board of Supervisors addressing issues identified in reviews of critical incidents (death and near death occurrences) and/or a review of organizational issues and practices within the general child protective system. All of the information outlined in this report is general and does not purport to be related to any particular case, person, or occurrence. A Sacramento County Superior Court order prohibits members of the Oversight Committee from disclosing specific confidential case information. The Oversight Committee wishes to thank the Sacramento County Department of Health and Human Service (DHHS) and CPS staff, especially Sherri Heller and Michelle Callejas for being responsive to the inquiries made by the Oversight Committee, and their willingness to make continual improvements. The collaborative culture between CPS and the Oversight Committee is essential for the improvement of the safety of children and families in our community.

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TABLE OF CONTENTS History and Role of Child Protective System Oversight Committee....4 Critical Incidents Subcommittee Summary of Findings ...5 Child Protective Services Quality Assurance Framework.....7 Alignment of with Previous Oversight Committee Recommendations....8 Implementation of Quality Assurance Framework and Role of Oversight Committee .......9 Conclusion ..11

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History and Role of the Child Protective System Oversight Committee During the 2012/13 year the role of the Oversight Committee and its scope was clarified. Michele Bach, County Counsel, began coming to Oversight Committee meetings to provide guidance and opinions as to the Oversight Committees role and scope. A thorough analysis of the history of the Oversight Committee was conducted by reviewing past reports and orders which culminated in a memo from County Counsel to the Department of Health and Human Services Director. Below is a summary. The Childrens Coalition was established by the Board of Supervisors in 1994. It is charged with assessing community needs, and evaluating existing services relating to the health and wellbeing of children. By resolution of the Board of Supervisors, the Childrens Coalition is responsible for, among other things, providing community oversight of the Countys child protective systems through the Coalitions Child Protective Systems Oversight Committee. In January 1996, the County Executive appointed the Critical Case Investigation Committee (CCIC) and charged it with examining and evaluating the child protection system in the context of its nexus to the homicide of Adrian Conway. Its primary purpose was to examine the Conway case to evaluate the efforts of all service providers, including DHHS, Family Preservation and Child Protection Division. In May 1996, the CCIC issued its final report. It recommended establishment, within an existing community advisory group, of the function of community oversight of child protective services, including preparation of an annual report to the Board of Supervisors on outcomes and effectiveness of the system along with recommendation for policy and program changes. It identified a nonexclusive list of areas which the annual report should address: Findings from the Child Death Review committee and assessment of impacts on the child protection system; Overall statistics and program analysis; A quality assurance review of at least one operational unit in the child welfare system; Comparison of outcomes for children with other communities in the state and nation; Identification of exemplary programs and practices with recommended application to the County; Report on community satisfaction with the child protection system; and Review and report on progress on recommendations contained in the CCICs report.

In July 1996, the Board of Supervisors approved DHHS recommendation that the Board of Supervisors establish the Childrens Coalition as the oversight body called for by the CCIC. The Bylaws of the Children Coalition define the duties of the Oversight Committee. The Oversight Committee is responsible for performing community review of critical child protective services cases, culminating in an annual report, which includes outcomes and effectiveness of the system with recommendations for policy or program changes. The report may include review of progress on the recommendations contained in the CCIC report and other items identified in the 1996 CCIC report. It must be approved by the Childrens Coalition which presents the report to the Board of Supervisors.

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The Oversight Committee has authority to conduct a community review of critical child protective services cases. Thus, the Oversight Committee is not limited to reviewing only death or near death cases. It may conduct a community review on a broader range of cases. However, the definition of what constitutes a critical case is unclear. Its scope should be clarified through discussions with DHHS, and preferably memorialized in writing. This Office of County Counsel recommends that DHHS work with the Oversight Committee in identifying criteria for determining whether a case constitutes a critical case within the Oversight Committees authority to review. As of the writing of this report, the Oversight Committee has agreed to review the Quality Assurance Reports that fall within CPSs definition of Major Incidents, described later in this report. The Oversight Committee is not limited to scrutinizing the CPS Division. It can, in its discretion, expand its inquiry to the Countys child protective services system generally, including service providers under contract with the County. Such an examination would necessarily be more systemic in character as access to an individuals records would be limited based upon a spectrum of confidentiality laws. The Juvenile Court order allows access only to those records that fall within the purview of Welfare and Institutions Code section 827, i.e., records related to dependency proceedings. Ultimately, the decision as to the focus and extent of its oversight functions rests within the exclusive determination of the Oversight Committee, subject to any limitations in the Coalition Bylaws or Board of Supervisors action. Critical Incidents Subcommittee Summary of Findings The Critical Incident Subcommittee of the Child Protective Systems Oversight Committee meets monthly to examine the child death and near death situations that occurred in Sacramento County over the previous year to determine if a systems failure or other failure was present in prior CPS or systems contact with the victim or family. This information can be used by partners in the child protective system to improve their practices and avoid repeating the mistakes of the past. Year after year past Child Protective Systems Oversight Reports have documented areas of failure to include a lack of understandable and useable policies and procedures; a lack of a thorough quality investigation; and a lack of engaging critical thinking skills to reach an appropriate disposition even when the facts are thoroughly discovered. In addition, Sacramento County CPS was singled out when the California State Joint Legislative Audit Committee heard testimony regarding the competency of CPS statewide in June 2013 that included a statement from senior counsel from the Childs Advocacy Institute of the University of San Diego School of Law, We need to know that policies and procedures exist and are followed, what we know from L.A. County and what we know from Sacramento County is that they are not always in place or they are not always followed. Sacramento Bee June 6, 2013 ppB1/ B4. Unfortunately, in the critical incidents reviewed this year the mistakes of the past have been repeated. During the 2012/13 period, CPS delayed sending their Quality Assurance Reports to the Oversight Committees Critical Incident Subcommittee to focus on the creation of the Continuous Quality Improvement (CQI) framework that will incorporate investigation, disposition, and quality council. While the CPS Oversight Committee supports CQI framework and will have members who participate in that task, it is hoped that its formation will result in true change that brings heightened protection to children in Sacramento County. Traditionally the cases examined come from reviewing the Quality Assurance Reports or memos (prepared by CPS) in response to the death/near death of the child that are reported to the State. In our 2012 report, eight 2011/12 cases were reviewed. Each was examined to determine if the CPS response prior to the death/near death of the child failed in one or more of the critical areas of a thorough quality investigation, and if the disposition related to that investigation was sound. Recommendations for improvement were made.
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For 2013, nine cases were reviewed. DHHS completed Quality Assurance Reports in five of those cases, and completed short memos in the remaining four. The memos provide very little information because the family had no recent history with CPS. A common theme exists between the 2011/12 and the 2012/13 cases reviewed: the same investigative or decision-making errors contributed to placing the child in a dangerous situation as a result of incorrect dispositional findings. In one case of near death of an infant, the mental health system had information that if conveyed to CPS clearly would have shown the child was in danger and that the safety plan in place was inadequate and unrealistic. In another case of death, the mental health system had direct information that the childs care giver suffered from suicidal ideation and that there was a lengthy history of referrals for rough treatment and neglect of the children in that persons care. This committees observation is that mandated reporters in the mental health system are hesitant to report due to a misunderstanding of their responsibilities under mandated reporter laws. Eight cases involved children two years of age or younger. The ninth case was the death of an eight year old. Eight of the nine cases had some history of CPS involvement, either with the victim, siblings, other family members, or with the parents when they were children. While it is clear that prior CPS involvement at any point does not necessarily mean that CPS had a realistic opportunity to intervene, this is an indication prior CPS involvement needs to be a considered factor in current evaluations. Prior unfounded or unsubstantiated cases should never leave a current worker with the conclusion the child is currently safe or that the prior risk assessment tool has been done correctly. In one case, a prior report was unfounded when the parents left the child with an unsafe caregiver. The disposition was unfounded, even though the allegations were true, because the worker did not want the parents to suffer a substantiated disposition. That same child was later left with a different unsafe caregiver and murdered. While CPS may not have had an opportunity to evaluate the second unsafe caregiver, a substantiated disposition on the first referral would have provided the young parents with services that might have been beneficial. In four out of the five Quality Assurance Reports, confusing, inadequate or unusable policies and procedures played a role in the disposition of the prior CPS involvement. This has been a main focus of the CPS Oversight Committee since its inception and is an area where CPS workers who were surveyed last year expressed genuine concern. CPS has promised improvement for several years. As of this date, there has not been improvement and the Policies, Procedures & Processes (PPP) appear to remain a work in progress. For example, a case of near death of an infant involved the policy and procedures surrounding a safety plan with a mentally unstable and homicidal parent who had made previous attempts to harm the child. Although the worker attempted to follow the PPP regarding safety plans, the policy provided minimal guidance and did not reflect current information regarding safety plans. As a result, the safety plan in place was problematic. The five Quality Assurance Reports highlighted other areas of concern that were not adequately assessed during the investigation such as assessing for domestic violence, alcohol and other drug issues, CPS closing out a referral when a family is not easily located, and failure to cross report to law enforcement. The memos on the remaining four cases do not provide enough information to know if these issues were present in the past referrals of those cases. Children who were experiencing these issues 17 years ago in 1996 are parents today and the same systemic problems still exist. These problems existed prior to the current administration; however, it is their responsibility to effect change.

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Child Protective Services Quality Assurance Framework The Oversight Committee supports the newly developed Quality Assurance Framework being implemented by the current Child Protective Services (CPS) administration. In the 2012 Oversight Committees Annual Report to the Sacramento County Board Supervisors, the recommendation that CPS operate within a Quality Assurance (QA) Framework was one of our main recommendations. While CPS had in place some elements of a QA Framework, namely critical incident reviews, QA Reports and outcomes data, it lacked an overarching structure and processes to systematize, coordinate, and sustain the learning derived from these efforts. As stated in CPSs May 29, 2013 Budget Letter to the Board of Supervisors, CPS does not currently have formal mechanisms to track the efficacy of improvement efforts at the program level. Other gaps in CPSs previous approach to quality assurance as stated in their letter include: Existing QA staff are not solely dedicated to QA functions, which limits their ability to increase the breadth and depth of QA reviews; QA reviews are conducted only for the Emergency Response program not for Dependency or other CPS programs, resulting in missed opportunities for improving permanency, safety and well-being outcomes; There are few vehicles for obtaining feedback from line staff; Youth and family voices are not included; and There are no feedback loops to ensure continuity of the improvement process.

Closing the above gaps by implementing an integrated, effective and sustainable QA Framework is critical to improving safety, increasing permanency, and achieving well-being for children and families. On June 11, 2013, the Sacramento County Board of Supervisors approved funding for the implementation of a Quality Assurance Framework within Child Protective Services Division. With a fully implemented QA Framework, The Oversight Committee feels this strategy would create a true learning culture, strengthen critical thinking skills, would improve case reviews, and enhance the overall quality of investigations; all of which would lead to improved outcomes for children. In addition, a fully funded and functioning QA framework would address inefficient business processes, identify the need for specific professional development, and discuss openly with all workers the cases where outstanding case work occurred and where case work procedures could be greatly improved. According to planning documents, CPS recognizes that they must have all the following elements in place: Adequate number of staff that are solely dedicated to QA functions QA reviews are conducted for Emergency Response, Dependency and other CPS programs Numerous avenues for obtaining feedback from line staff and the request for feedback must be authentic to ensure continuous improvement Voices from youth and families are needed Identifying and fully communicating priorities and expectations to entire CPS staff Identifying needed system improvements based on data reviewed Monitoring system improvement initiatives Reviewing outcomes and process measures Tracking corrective action plans related to case-specific findings related to the continuum of care

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Alignment with Previous Oversight Committee Recommendations The Oversight Committee conducted an extensive review of past annual reports and found re-occurring recommendations starting in the first report in 1996. When the QA Framework is fully implemented and funded our members are hopeful these re-occurring recommendations will have meaningful solutions attached to them. The purpose of highlighting re-occurring themes is to stress the importance of the need to fully fund and implement the QA Framework. The Oversight Committee is in agreement with Sacramento County CPS in adopting the QA Framework. The Oversight Committee recommended to the Sacramento County Board of Supervisors that they adopt and fund the QA Framework. A. Risk Assessment Tools One of the re-occurring recommendations concerns the use of risk assessments tools. This specific recommendation is mentioned in all reports starting from 1996 through 2012. It is important to note CPS has addressed this issue in the development of risk assessment tools particularly with the introduction of Structured Decision Making (SDM). In our 2012 annual report, the Oversight Committee highlighted the improvement that CPS has made in this area with use of the SDM tool. However, based on the critical incidents subcommittee reports reviewed, and reports from Social Workers, how risk assessments tools are used is not consistent throughout the departments. The QA Framework will address the how in an attempt to achieve greater safety for children and families served. In 1996 Recommendation six stated, The Division should fully use its existing unabridged assessment tool. DHHS should also participate with the State to evaluate and improve the risk assessment instruments. Assessment tools must be used in conjunction with sound clinical judgment. In 2000 Recommendation fourteen stated, A checklist must be used to ensure that these critical factors are not overlooked. The new risk assessment tool may serve as this checklist and should be used consistently. In 2007 Recommendation four stated, Explore current policies and corrective action plans regarding the use of SDM; specifically, that the supervisors ensure ER workers are correctly using the tool, that the tool is not completed post assessment, and SDM training is an ongoing process, not one that is completed in a specific point of time. In 2012 - Recommendation five in the 2012 annual report was Conduct through investigations of every open referral and its unique circumstances within a minimum standard of operation based on best practice. The Oversight Committee is hopeful that the implementation of a fully funded QA Framework will assist in achieving these recommendations. B. Policies and Procedures Another re-occurring theme in our annual reports from 1996 through 2012 is challenges around Policy and Procedures. It is important to note Sacramento County CPS has made some progress in addressing the challenges around Policies and Procedures. In 1996 Recommendation three stated, Division management should review and remove inconsistencies between written policy, verbal directives and case practices. In 2002 Recommendation six stated, CPS management and supervisors verbal directives should reflect the written policies and should enforce them with the social workers in case practices. Appropriate corrective
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action must be taken when social workers and supervisors do not adhere to the written policies and procedures. Policies and procedures should be revised to remove any inconsistencies and ambiguities. In 2010 and 2011 - Recommendations were made to accelerate the timeline and revision of all polices and procedures. In 2012 - Recommendation two stated, Prioritize the completion, dissemination, and training of meaningful and useful Policies, Processes and Procedures as they are the function of standardized operations. In the information provided to the Oversight Committee from CPS, it clearly states that the newly created QA Framework is a mechanism where updates, and changes to the policies and procedures can occur. Implementation of Quality Assurance Framework and Role of Oversight Committee The CPS QA Framework is designed to measure the quality of services provided to children and families and the effectiveness of the processes and systems utilized to deliver those services. This framework incorporates a continuous quality improvement approach which will allow CPS to identify, quantify and analyze strengths and gaps and to test, implement, learn from and revise solutions. It represents a key strategy for creating a learning culture, strengthening critical thinking and improving outcomes. It is also a vehicle for increasing accountability at all levels of the organization. The Oversight Committee will monitor CPS as they implement the QA Framework by working with CPS to develop metrics to evaluate the efficacy and implementation of the QA Framework. The ultimate goal is improved outcomes for children so that the same recommendations do not need to be made year after year. Members from the Oversight Committee will serve on the Quality Improvement Committee (QIC). In addition, the critical incidents sub-committee of the Oversight Committee will continue their essential review of all critical incidents. In order to achieve the best possible outcomes for children and families the QA Framework will assist in continually refining practices and protocols. As stated in CPSs Budget Letter, the objectives of this framework include: Identifying and communicating Division priorities and expectations, including its Mission and Core Values Reviewing trends and findings from critical incidents and on-going case reviews covering the continuum of care Identifying needed system improvements based on data reviewed Monitoring system improvement initiatives and initiating needed refinements Making recommendations for QA activities including Practice Improvements Groups topics Tracking corrective action plans related to case-specific findings related to the continuum of care Reviewing outcomes and process measures Developing goals for and monitoring progress of the System Improvement Plan (SIP) Disseminating outcomes data to stakeholders

The plan presented to the Oversight Committee states that the QA Framework will be administered by the QIC which will use data to expand knowledge about agency performance and in turn, guide improvement strategies. It will set priorities and expectations and will communicate them to staff at all levels of the organization. The Oversight Committee understands that the QIC will: Prioritize issues/practices to be reviewed
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Review Critical Incident Reports/Memos and finalize the Critical Incident Summary reports that go to the Oversight Committee Develop Critical Incident Action Plans Review all logic models Review data and outcomes that encompass the entire continuum of care Identify case reviews to be conducted throughout the entire system Monitor and evaluate system wide implementation and improvements Review outcome trends and observations from data covering the continuum of care (including data book) Make recommendations for quality assurance activities, including PIGs topics Track follow up from case specific actions related to the critical incidents, continuum of care case reviews and the PIGs Develop and monitor SIP goals

CPS worked with the Casey Family Foundation to develop and implement the Quality Assurance Framework. The Oversight Committee recommends CPSs continued partnership with the Casey Family Foundation to develop an evaluation plan and measurable outcomes within a specific timeline to track progress and determine if the QA Framework is working and demonstrating the anticipated results. Progress made and outcomes of the Quality Assurance Framework should be regularly reviewed and results should be shared with stakeholders, community service providers, and community members. The Oversight Committee will serve the important function of offering an outside perspective into case reviews, observations, trends, and recommend actions necessary. The Oversight Committee representation on the QIC will allow for the Oversight Committee to follow-up on Practice Improvements Groups when they are assigned and their outcomes. This also establishes the Oversight Committees ongoing role in QIC for quality assurance, monitoring the work of the QIC, and to make broader recommendations regarding QIC generally. In addition to its role on the QIC, the Oversight Committee will continue to convene its Critical Incident Subcommittee and review Major Incident QA Reports. CPS had defined Major Incident as those involving any of the following: Child death Near fatality, which according to the California Department of Social Services, is a severe injury or condition that is either: o Reasonably suspected and/or confirmed to be caused by abuse or neglect; and/or o Results in the child receiving critical care for at least 24 hours following the childs admission to a critical care unit(s) Incidents involving severe trauma to a child including but not limited to: o Injuries such as multiple broken bones and severe burns o Any injury to an infant including sexual abuse o Circumstances indicative of severe or frequent abuse over time Any situation likely to generate media coverage, such as: o Child witnesses a murder; or Youth attempts suicide. Pursuant to County Counsels recommendation above for DHHS and the Oversight Committee to define the scope of critical cases to review, the Oversight Committees Critical Incident Subcommittee recommends reviewing cases that fall within this definition of Major Incidents. Although the QIC is in place to review cases internally, the Oversight Committee feels there is an important need for an outside body to review these same cases and provide its own recommendations to the Board of Supervisors. This is consistent with the bylaws stated above to provide a community review of critical incidents to recommend policy and program improvements.
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Conclusion This report is different from the Oversight Committee Annual Reports from the past. Specifically, the Oversight Committee only received five Quality Assurance Reports, which is too few from which to identify issues and trends, but is sufficient to see that the issues of the past still exist. The Oversight Committees Critical Incident Subcommittee is an integral part of the community oversight function of the Oversight Committee and will provide an important role in providing an outside community perspective for the improvement and effectiveness of the overall child protective system. The Oversight Committee is hopeful that the Quality Assurance Framework will contribute to the development of a learning culture and improved outcomes for children and families within the Child Protective Services system. The Oversight Committee will continue monitoring its implementation, progress and outcomes through the review of critical incidents, following the implementation of the QIC recommendations, and by making its own recommendations for future improvements. The time for action is now. The time for improved practices and better outcomes for children is long overdue. Independently of the Quality Assurance Framework, the Oversight Committee will assess how these changes incorporate the recommendations from the last 15 years and ultimately improve outcomes for children.

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